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Printer Friendly Version Pain Control Infusion Pump

Pain Control Infusion Pump

DESCRIPTION

This disposable device involves infusion of a local anesthetic into an intraoperative site for postoperative pain management. A catheter is inserted into the intraoperative site following shoulder or anterior cruciate ligament (ACL) surgery. The device enables continuous delivery and local infiltration of the intraoperative site with a local anesthetic solution, usually bupivacaine. There are several devices approved by U.S. Food and Drug Administration (FDA) for marketing. The following list includes some examples (Note: may not be inclusive):

Sgarlato Laboratories Pain Control Infusion Pump formerly known as "SurgiPEACE®"
I-Flow PainBuster® Pain Management System may be referred to as "Marcaine pump"
Ipump^TM Pain Management System
Baxter Pain Management System marketed as Baxter Infusor Devices (Infusor SV, Infusor LV)
P.O.P. Post Operative Pain Kit common name Elastomeric Infusion Pump Kit
Pain Care 3000
CADD® Ambulatory Infusion Pumps
ON-Q PainBuster®
Stryker OutBound® PainPump
Go Pump Rapid Recovery System

POLICY

Use of a pain control infusion pump may be considered medically necessary in the postoperative period when inserted during surgery of the knee or shoulder.

However, the charges for this disposable device should be included in the surgical facility's claim. This device does not meet the criteria for Durable Medical Equipment and may not be billed separately. It is not appropriate for providers to bill the patient for this service.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

2/1999: Approved by Medical Policy Advisory Committee (MPAC)

1/18/2001: Policy revised

5/2/2002: Type of Service and Place of Service deleted

6/23/2004: Policy reviewed, no changes

11/19/2004: Code Reference section reviewed, table added, there are no specific codes

9/21/2005: ON-Q PainBuster® added to Description section

8/7/2006: Policy reviewed, Stryker OutBound® PainPump added to Description section

12/31/2008: Policy reviewed, no changes

SOURCE(S)

Hayes Medical Technology Directory

CODE REFERENCE

All codes are non-billable for this service. There are no specific codes.

Non-Covered Codes

Code Number	Description
CPT-4

ICD-9 Procedure

ICD-9 Diagnosis

HCPCS

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